Endodontic Topics 2004, 7, 5272

Printed in Denmark. All rights reserved

Copyright r Blackwell Munksgaard

ENDODONTIC TOPICS 2004

Advanced radiographic techniques

for the detection of lesions in bone
ELISABETTA COTTI & GIROLAMO CAMPISI
Radiographs in endodontics are of importance for the study and management of periapical lesions. With the
development of advanced systems in traditional radiology, new and more accurate imaging techniques are
constantly under investigation. Computerized tomography, magnetic resonance and real-time echotomography
have been introduced in recent years to the field of endodontics: they may have advantages over conventional
techniques for the amount of detailed information they can provide on specific cases. This paper reviews these new
imaging techniques with respect to their possible role in the diagnosis and management of periapical lesions.

Conventional radiographs traditionally form the backbone in the diagnosis, treatment procedures and
follow-up of endodontic cases (Fig. 1ac).
One of the most important roles played by imaging in
clinical endodontics is the possibility of diagnosing and
describing lesions in the jaw bones that originate from
infection of the root canal (Fig. 2ac).
Most of the osteolytic lesions in the jaws are in fact
related to chronic apical periodontitis. The so-called
bony lesions of endodontic origin are a common
finding in dental radiology and are generated by the
pathologic changes occurring in the periradicular
tissues as a consequence of pulpal infection and
necrosis. Periradicular tissues surround and interact
with the root of the tooth. They originate from the
dental follicle, which surrounds the enamel organ, and
this unit consists of the cementum, of the periodontal
ligament (with its bundles of collagen fibres, extensive
network of vessels and nerves) and of the alveolar bone.
The interaction between the irritants exiting the root
canal to the periradicular tissues and the host defence
results in the activation of both non-specific inflammatory reactions and specific immune reactions.
As the disease proceeds, soft tissues produced by the
inflammatory reaction substitute the periapical bone.
Besides the possible clinical signs and symptoms
associated with the different stages of this condition
(such as swelling-sinus tracts- pain to percussion of the

52

tooth and palpation of the area) there are changes in

the mineralization and structure of the bone that can
be visualized by radiographic techniques (13). Periapical lesions of endodontic origin in the maxillary and
mandibular bone may be distinguished into cysts and
granulomas depending on their nature and histopathological features. Making a differential diagnosis between a cyst and a granuloma may have some
importance in the management of the lesions, with
special regard to the predictability of endodontic
treatment success and the possible explanation of
failure (2, 4, 5).
In order to investigate and screen pathologic
conditions of the jaws, especially if they originate from
an endodontic infection, conventional imaging techniques may be obtained with traditional radiology by
means of intraoral periapical, occlusal and panoramic
radiographs. Furthermore, digital radiography has, in
the last 10 years, become extremely valuable as an
alternative to conventional radiology with a significant
reduction (5080%) in radiation exposure and with
possibilities of color-enhancing systems and densitometric and subtraction methods (6).
But conventional radiographs have limitations that
have stimulated an extensive search for improvement.
Radiographs are the two-dimensional projection of
three-dimensional (3D) structures; most of the times
they are not sufficient to provide information on the

Advanced radiographic techniques for the detection of lesions in bone

clinician towards a diagnosis of the soft tissue
characteristics of the lesions (5).
Furthermore, they require careful interpretation and
are prone to observer bias (6, 10).
Supporting these traditional imaging methods, partly
overcoming some of the limitations of the techniques,
and sometimes gaining more specific information that
can be used either for diagnostic purposes or for
investigation protocols, more advanced diagnostic
systems have been applied to endodontic situations in
the past 1015 years, namely, computerized tomography (CT), nuclear magnetic resonance and ultrasound
real-time echotomography.

CT

Fig. 1. Importance of periapical radiographs during

endodontic treatment. (a) Lower left second molar;
perforation of the floor of the pulp chamber (arrow).
(b) Identification of the perforation site and of the distal
canal (c) Root canal treatment has been completed and the
perforation has been repaired (arrow).

actual size of the lesions (7, 8), their spatial relationship

with anatomic landmarks (9), and it has been proposed
that the amount of bone that has to be resorbed before
a lesion becomes clearly visible is quite extensive (9).
Radiographs are limited to visualization of hard tissues
and not of soft tissues; therefore, they cannot guide the

Hannsfield (11) devised the computerized axial tomography during the 1970s.
CT is an X-ray imaging technique that produces 3D
images of an object by using a series of two-dimensional
(2D) set of image data to mathematically reconstruct a
cross-section of it. This system measures the attenuation of X-rays entering the body from many different
angles. The computer then reconstructs the part under
observation in a series of cross sections or planes.
CT is unique in that it provides imaging of a
combination of soft tissues, bone and vessels, and the
technique has become a widely used method for the
diagnosis of pathologic conditions in the maxillary
bones and plays a major role when used following a
preliminary screening with a panoramic or a periapical
radiograph. Many studies have confirmed CT to be a
valid complement to conventional imaging methods
(12). Historically, before dental CT was introduced
to study the anatomy and pathology of the jaw
bones, conventional orthoradial tomography associated with a complex blurring device (Scanora,
Soredex, Helsinki, Finland) was applied to dental and
oral tissues.
Conventional orthoradial radiography is still in use
today, but it takes a longer time in order to allow
imaging of the complete jaw and it is less accurate and
more prone to errors (13). A study by Tammisalo et al.
(14) demonstrated that in the overall diagnosis of
periapical and periodontal lesions the Scanora system
and periapical radiographs performed equally well,
tomograms being more detailed only for detecting
periapical lesions in posterior regions. There are several

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Cotti & Campisi

techniques related to CT in the dental field: dental CT,
ortho CT, local CT, tomosynthesis and tuned aperture
computed tomography (TACT), and micro-CT.

Dental CT
Dental CT was introduced in 1987 and it is defined as a
technique, which uses a specific protocol of investigation (15, 16). In dental CT, axial scans of the jaws are
acquired using the highest possible resolution, and
curved as well as orthoradial multiplanar reconstructions are obtained.
The coronal plane is not generally used for the scans
in dental CT, since the metal artefacts from teeth
fillings and other metal-dental work are frequent and
appear in these sections. Using the axial planes, the
occlusion plane will still have the artefact displayed, but
the bone will be left undistorted.
Dental CT can be performed with a conventional CT,
a spiral CT or a multislice CT scanner. The device
should give high-resolution scans with a small focal
spot and the acquired slices should be of 1.5 mm
thickness or less.
The slower the rotation of the tube, the more detailed
is the information gained. In order to achieve routine
images of the jaws, a spiral scan technique of 1 s per
rotation is valid; if small details need to be obtained for
diagnostic purposes, then 2 s per rotation need to be
used. The standard protocol for dental CT in the
diagnosis of pathologic conditions is as follows:
Incremental scan type; 1.5 mm slice thickness; 1.0
table feed; 120 mm field of view (for the mandible);
100 mm field of view (for the maxilla); 2 s scan time;
512 matrix; 12 kV; 25100 m A; high-resolution edge
enhanced filter, 20001400 HU (Hounsfields units)
bone window; mandible base and hard palate as scan
planes (17).
After the examination is completed, the axial slices are
transferred to a workstation to perform multiplanar
reconstructions; this is accomplished through dental
software.
The multiple orthoradial reconstructions are calculated perpendicular to a planning line that is manually
drawn along the centerline of the jaw arch. The distance
between each of the 4060 cuts is of 1.53.0 mm (Fig.
3). Panoramic reconstructions are calculated along the
3

Fig. 2. Lesions of endodontic origin in the jaws as shown

in periapical radiographs. (a) Upper left lateral incisor;
deep caries and periradicular lesion. (b) Lower right
first molar; deep caries and periradicular lesion. (c)
Radiograph showing 1-year follow-up of the same
tooth: healing of the lesion is evident and the bone
pattern has been re-established.

54

Advanced radiographic techniques for the detection of lesions in bone

Results from the application of dental

CT in endodontics

Fig. 3. Dental computerized tomography examination

of the maxilla in a case of extensive periapical lesion.
Reconstructions are performed from axial slices.

planning line. For a single jaw scan, all images can be

displayed on three hard copies for an overview of the
complete investigation: the first two showing the axial
scans. The third copy displays the dental reconstructions in a 1 : 1 scale, it includes also the planning line
and the orthoradial lines, plus the subsequent scans,
which are numbered, thus allowing a correlation with
the orthoradial reconstructions.
Panoramic reconstructions are shown in the same
copy and allow correlation with the orthoradial
reconstructions by indicating their position (Fig. 4ac).
A major concern related to dental CT is the high
radiation dose required for average exams; in the last
years dose reduction methods have therefore been
established (18).
Reducing the tube current is an important step for
dose reduction. This is followed by using a 1.5 mm slice
thickness instead of 1.0 mm, or using a spiral technique
with a pitch factor of more than 1.0. An additional and
important means of dose reduction is to limit the area
of interest for the investigation by selecting the upper
or lower jaw and excluding all the occlusal scans (which
are mostly useless and subject to artefacts from metallic
objects) (17, 18).
Spiral CT scanners use continuous scanning to
generate cross-sectional slices and make a set of 3D
images. In this way the time it takes to produce
tomographic pictures is reduced.

In normal and pathologic conditions the tissues of the

jaws that are visualized in dental CT are the alveolar
processes with the teeth, the base of the mandible with
its vessels and canals, the maxillary sinus; the floor of
the nose and the incisal canal.
The alveolar process is the portion of the mandibular
bone and of the maxillary bone that holds the roots of
the teeth, the periodontal ligament, the periapical
tissues and the lamina dura. The alveolar process is
therefore the area of major interest in the field of
endodontics: it is the area where most pathologic
changes occur involving the condition of the roots of
the teeth, the possible presence of foreign bodies, and
osteolytic or condensing inflammatory reactions in the
bone. The alveolar process is easily visualized in dental
CT, both in axial slices and in orthoradial reconstructions. The root of the teeth can be visualized; the
periodontal space can be discerned especially if there are
pathologic conditions. The mandibular canal is an
important feature of the imaging obtained scanning the
base of the mandible; if it is well surrounded by cortical
bone it is clearly visible both on axial scans and on
reconstructions. If the cortical bone is interrupted,
then the canal may be obscured from the surrounding
cancellous bone, but its position can be easily extrapolated by the reconstructions of slices where the canal
is visible.
The extension of the maxillary sinus and the floor of
the nose and their relationship with the roots of the
teeth are of great importance in the study of the origin
and dimension of endodontic lesions; dental CT will
offer a very good imaging of these structures (Fig. 3)
(17, 19).
Chronic apical periodontitis can also be seen with the
CT scan: when a lesion is at an early stage, or when the
slice covers the smallest portion of a well-established
one, it is seen as an enlargement of the periodontal
space, this can also be clearly seen as a small osteolytic
reaction around the roots tip (Fig. 4ac).
A reactive enlargement of the trabecular bone follows
this enlargement of the periodontal space. Further
expansion of the pathologic reaction in the cancellous
and cortical bone may easily be seen both on axial scans
and on the reconstructions, including a detailed
visualization of the involvement or erosion of the
cortical plates (9, 17).

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Cotti & Campisi

Fig. 4. Dental computerized tomography examination of the maxilla in a case of extensive periapical lesion. (a) Axial
slices of the maxilla showing an extensive periapical lesion of endodontic origin. There is a significant amount of bone
destruction and the root of the tooth is visible in all the slices (arrows). (b) Lower axial slices of the same case. The roots
of the teeth of the maxilla are visible, with their periradicular bone (long arrows). In the upper slices the lingual cortical
plate shows signs of erosion and displacement (short arrows). (c) Panoramic and orthoradial reconstructions of the same
lesions showing the alveolar crest (black arrows) and the maxillary sinus (white arrows).

While vertical root fractures or split teeth can seldom

be seen by means of a normal periapical radiograph, they
may be more easily detected in CT scans. Limitations are
related to small fractures that are below the resolution
power of the CT, or to the superimposition of metal
restorations (20). CT may also be applied for localizing
the presence of foreign bodies in the jaws (17).
Trope et al. (21) pioneered the application of CT to
endodontic imaging. They evaluated eight periapical

56

lesions on human cadavers with a CT scan, axial slices

and a densitometric processor. The computerized
examination of the lesions was correlated to the
histopathology. They concluded that cystic cavities
could be differentiated form granulomas based on their
appearance in the tomographs. They observed that a
cyst would appear as an area markedly darker when
compared to a granuloma or to the fibrous tissue of an
apical scar. The cystic area would have a density reading

Advanced radiographic techniques for the detection of lesions in bone

similar to the background, while the granuloma would
show a cloudy appearance with a density similar to the
one exhibited from the surrounding soft tissues.
Marmary et al. (9) used a high resolution dental CT
(object size 5 0.250.3 mm) to examine 42 periapical
lesions that had been diagnosed using conventional
periapical radiographs. By performing axial slices and
using reconstruction software, they obtained a series of
cross sections of the jaws. Periapical lesions would occupy
an average of 34 mm sections one of which would
demonstrate the widest bucco-lingual dimension of the
lesion. With this system, they found that the margin of
the cortex and the periphery of the lesion could be easily
identified in cross-sectional reconstructions. They demonstrated that 74% of the lesions observed were in fact
confined to the cancellous bone without any kind of
erosion or involvement of the cortical plates. Using this
sophisticated examination, they also observed that the
erosion of the cortical plate in cases of periapical lesions
might be largely a consequence of the spatial relationship
of the cortices to the apices of the teeth involved.
After several years of experience with applications of
CT examinations in the dental clinics at the University
of Cagliari, we have found the large amount of detailed
information that can be gained in cases of extensive
periapical lesions of endodontic origin to be very useful
(Fig. 5). The information is especially important when
a complex surgical procedure has to be planned and
when there are doubts concerning the lack of healing of
apparently correctly treated cases. E.g., particular in
one case that we reported (22) a wide lesions of the
maxillary bone was examined and followed-up using
both CT scan and panoramic radiograph. Here the real
extension of the lesion, the erosion of the floor of the
nose and of the mesial wall of the naso-palatine canal
could only be seen in detail using axial slices of the CT.
Concerning follow-ups, the panoramic radiograph at
18 months recall disclosed the appearance of a lesion
that would have been considered healed for about 70%
of its extension when compared with the starting
radiograph, however, the CT demonstrated that this
apparent healing was seen because the external cortical
plate, which was previously eroded, had been regenerated; but the size of the lesion had not decreased
anywhere near the extent that was inferred from the
panoramic radiograph (Fig. 6ad).
From a case like that, one may speculate that the
healing process of a large bone lesion starts with the
reconstruction of the external cortical plate and is

followed much later by the formation of cancellous

bone and the repair, in this case, of the floor of the nose.
In another case followed by CT, a persistent lesion in
the periapical region of a right maxillary canine with a
wide apex, besides giving information on the overall
characteristics of the lesion, the CT showed the
presence of a foreign particle that recalled the aspect
of dental tissues. During the surgical procedure, the
foreign body was removed from the area and after
examination it appeared as piece of the root that was
probably displaced after a traumatic injury and had
since acted as an irritant (Fig. 7ad).
Another case displayed a dense bone reaction in the
periradicular space of an endodontically treated right
mandibular molar (Fig. 8a, b).
Velvart et al. studied in vivo 50 mandibular posterior
teeth affected by periapical pathosis and scheduled for
endodontic surgery. They compared the information
obtained on the use of high resolution CT scan with
those gained from conventional periapical dental radiographs. The information was then correlated to clinical
findings during surgery. They found that all the
information achieved by means of the tomographs were
more detailed regarding the presence, characteristics and
location of the lesions, and provided important imaging
concerning the relation of the lesions to the mandibular
canal. They therefore concluded that CT should be
seriously considered before endodontic surgery (23).

Dental CT in the differential

diagnosis of periapical lesions and
other pathologic conditions of the
jaws
There are few lesions in the jaws that may present
difficulties in the differential diagnosis with apical
periodontitis because they are relatively well-circumscribed radiolucent lesions (24). The most common are
the non-endodontic odontogenic cysts such as the
lateral periodontal cysts, the odontogenic keratocysts,
and the dentigerous cyst. Among the other lesions are
the non-odontogenic developmental cysts, the traumatic bone cysts and some forms of ameloblastoma.
Cemental dysplasia is the most common sclerotic
lesions of the jaws. CT has been used with success to
help in the differential diagnosis of these lesions.
The odontogenic keratocysts is a developmental
lesion derived from the remnants of the dental lamina.

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Cotti & Campisi

58

Advanced radiographic techniques for the detection of lesions in bone

Fig. 6. Lesion of endodontic origin in the periapical areas of the upper left front teeth. (a) Periradicular lesion as seen in
the panoramic radiograph. (b) The same lesion as seen in the axial slice of the computerized tomography (CT). The major
diameters of the lesion and the erosion of the external cortical plate and the involvement of the incisal canal (arrow) are
shown. (c) Healing of the same lesion as seen in the panoramic radiograph 18 months after endodontic treatment.
Healing appears close to be completed. (d) CT axial slice of the lesion at the 18 months follow-up. The CT shows that the
external cortical plate has been repaired (arrow), but the lesion in the bone is still large.

Fig. 5. Lesions of endodontic origin in the periapical area

of upper left canine. (a) Periapical lesion on upper left
canine. In the periapical radiograph, it is not possible to
visualize the extension of the lesion. (b) Periapical lesion
of the same tooth as shown in an axial slice on
computerized tomography (CT) (arrow). The root of
the tooth is visible, the extension of the lesion in its major
diameters and the external cortical plate perforation are
evident. (c) More cranial axial slices from CT of the same
lesion. The extension of the lesion and the involvement of
the floor of the nose are clearly shown.

It has a preference for the posterior body and ramus of

the mandible. Radiographically this lesion has a varied
appearance: a well-defined radiolucent lesion; a radiolucent lesion associated with a tooth (not distinguishable from a dentigerous cyst), or an expansive
multilocular or unilocular lesion (similar to the
ameloblastoma). As a consequence of all these forms,
the keratocysts should always be considered in the
differential diagnosis of the cystic lesions in the jaws,
and this is important also because this lesion has a

59

Cotti & Campisi

Fig. 7. Endodontic lesion in the periapical area of the upper right canine. The tooth had a history of trauma, a short root
with open apex, and was refractory to apexification treatment with calcium hydroxide. (a) The upper right canine in the
periapical radiographs. The short root, the open apex and the periradicular lesion are seen. (b) One-year follow-up
periapical radiograph after apexification treatment was started; the lesion is unaffected and there is no evidence of apical
hard tissue barrier formation or periapical healing. (c) Computerized tomography examination of the lesion. The apex of
the tooth, the erosion of the external cortical plate and a small calcified particle (arrow) are shown. (d) After endodontic
surgery was performed, the calcified particle turned out to be a small root fragment. It was removed and the lesion was
curetted. The 1-year follow-up radiograph shows healing of the periapical tissues and formation of an apical barrier.

60

Advanced radiographic techniques for the detection of lesions in bone

Fig. 8. Radiopaque bone lesion in the mesial

periradicular area of the lower left second molar. (a)
Periapical radiograph showing the lower left second
molar and an area of radiopacity mesial to his mesial
root (arrow). (b) Computerized tomography axial scan of
the same area showing that the lesion is an enostosis with a
central area of bone sclerosis.

recurrence rate of 1360% after surgical treatment (Fig.

9a, b).
The dentigerous cyst is a common cyst of the jaws and
is located around the crown of an unerupted tooth as a
result of the cystic degeneration of the enamel organ.
This lesion also is more often located in the mandible in
the third molar area. The differential diagnosis of a
dentigerous cyst is usually less complicated because of
the association of this lesion with the crown of the
tooth (24) (Fig. 10a, b).
In a study that compared the morphology of these
three lesions (radicular cyst, keratocysts, dentigerous
cyst) based on CT scans (25), it was observed that the
odontogenic keratocysts and the dentigerous cyst tend

Fig. 9. Keratocyst of the mandible. (a) Panoramic

radiograph showing the lesion in the left mandible. (b)
Axial slice of the cyst showing the development of the
lesion, which is mostly parallel to the long axis of the
mandible. There is a visible expansion of the cortical
plates and the lingual is eroded (this is a frequent
occurrence with this kind of lesions).

to develop more in a direction parallel to the long axis

of the mandible rather than perpendicular to it; the
keratocysts tend to show a discontinuity in the lingual
cortex more often than the radicular cyst. They can
exhibit unilocular or multilocular patterns, but the
dentigerous cyst is almost always unilocular and may
present with a local expansion of the cortical plate. The
radicular cyst is mostly unilocular, shows discontinuity
of the cortex towards the lingual surface of the
mandible less often, has an overall rounder shape, and
is often surrounded by a sclerotic bone rim (Figs 4
and 6).
The nasopalatine canal cyst and the static bone cyst,
also called Stafnes cyst, are developmental, non-

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Cotti & Campisi

Fig. 10. Computerized tomography (CT) examination of

a dentigerous cyst of the left maxilla and of the right
mandible. (a) Axial CT image of the maxillary bone
demonstrating an extensive dentigerous cyst.The external
cortical plate has been invaded; the impacted teeth are
within the cyst (arrow). (b) Axial CT of the mandible
showing a dentigerous cyst, the crown of the impacted
tooth and its extension parallel to the major axis of the
mandible.

odontogenic cysts (24). The nasopalatine canal cyst

occasionally forms from proliferation of the epithelial
or mucous cells of remnants of the nasopalatine canal
and is usually asymptomatic. On panoramic radiographs it appears as an oval or heart-shaped radiolucent
lesion located between the roots of maxillary central

62

incisors. Sometimes it may be difficult to trace the

lamina dura of these teeth, thus rendering the differentiation of the lesion from apical periodontitis difficult.
On CT it appears as an enlargement of the nasopalatine
canal on axial or coronal sections through the anterior
maxilla. Multiplanar and 3D imaging may be important
to demonstrate the extent of this lesion (24).
The static bone cyst (24, 26) is a depression in the
lingual surface of the mandible; it results from aberrant
tissue of the submandibular gland. Usually located
below the level of the mandibular canal in the area
between the first molar and the angle, it may
occasionally be found in the anterior mandible, making
the diagnosis more challenging. Dental CT is considered the most suitable non-invasive diagnostic
modality for this bony radiolucency: it shows a wellcorticated defect in the lingual aspect of the mandible
and the associated glandular tissue (26).
The traumatic bone cyst is a cavity that may occur in
the posterior mandible. It is not lined by epithelium
and is therefore considered a pseudocyst. The causes of
its development are not clear; but it is supposed to be
the consequence of an intramedullary haematoma
following trauma (24, 27). A lesion that is detected
early may contain blood or serosanguinous liquid, later
it may appear as an empty cavity. Radiographically, it is a
well-defined radiolucent area, which may extend
between the roots of the teeth without causing
interruption of the lamina dura. On the axial CT scans
it typically show expansion with thinning and scalloping of the cortical plate and its possible fluid content.
The ameloblastoma represents approximately 1% of
the tumours of the jaws. It may be locally invasive and
may degenerate into malignancy. It is more often found
in the mandible (ascending ramus and molar region)
and derives from epithelial cells either from the dental
lamina or from an odontogenic cyst. Radiographically,
it shows a well-circumscribed multilocular or unilocular
radiolucent area, which may be associated with resorption or displacement of the roots of the teeth involved.
The differential diagnosis with periapical lesions is more
complex when the lesion is unilocular. The CT shows
the expansion of the bone and is very important in
following up the lesion at regular intervals (24, 25)
(Fig. 11a, b).
The giant cell granuloma is another lesion that occurs
more often in the mandible (anterior) and has the
radiographic appearance of an irregular radiolucent
area that may be unilocular or multilocular and tend to

Advanced radiographic techniques for the detection of lesions in bone

and at this stage the distinction from periapical lesions
may be difficult. A second stage shows a complex
radiographic appearance with a progressive development of coalescent radiopacities; in the final stage the
lesion is predominantly radiopaque. Axial CT scans are
useful to identify, describe and discriminate these
lesions: they show radiopaque masses surrounded by
low-density areas with no continuity with the cortical
plate (as in enostosis) and no continuity with the root
of the teeth (like in the cementoblastoma). In this kind
of lesions, the CT number of the pixels in the region of
interest (expressed in HU) of the high-density masses is
important to differentiate cemental lesions from
odontomas. The CT number for low-density masses
is influential in differentiating cemental dysplasia from
keratocysts. It is also important to distinguish cemental
dysplasia from fibrous dysplasia, which is a generalized
dysplastic condition (24, 28) (Fig. 12ad).

Alternative CT techniques

Fig. 11. Computerized tomography (CT) examination of

an ameloblastoma of the mandible. (a) Axial CT image of
the right ramus demonstrating an extensive unilocular
ameloblastoma involving the mandible. Both cortical
plates have been invaded. (b) Axial CT of the same
ameloblastoma showing its vertical extension and the
invasion of the cortical plates and soft tissues.

resorb the roots of adjacent teeth. Small lesions may

simulate the apical periodontitis. In CT scans they are
distinguishable because they are non-corticated (24).
Periapical cemental dysplasia is considered one of the
possible manifestations of cemento-osseous dysplastic/
reactive lesions of the jaws and is predominantly located
in the mandible. The initial phase is always radiolucent,

Because the CT instruments in use are usually large

devices, located in hospital facilities, expensive and
non-specific for dental applications, and with high
radiation doses involved in their use, different, alternative 3D imaging systems have been developed.
Ortho CT has been described as a compact CT
apparatus in which cone beam geometry is used to image
the maxillofacial area with high resolution. Data are
collected using a dental panoramic machine. In this
system, the entrance radiation dose is several dozen
times lower than that of conventional CT. Because of its
reduced field size, it is not possible to examine lesions
exceeding 30 mm without repeated scanning. Another
drawback is the inability of this technique to discriminate
soft tissues because of its low contrast resolution (29).
Tomosynthesis is an analogue of CT that uses a
number of conventional radiographic images on films
to extract a slice through the region of interest, by
overlapping the images and eliminating the unwanted
parts of the object. TACT is a more specific digital
version of tomosynthesis. It uses a fiducial mark for the
registration of the images and requires a conventional
radiographic apparatus, a digitising system and specific
software (30). It has been shown to visualize root canals
better than conventional radiographs (31), and is
suitable for evaluation of crestal defects in the jaws (32).
Local CT is an imaging geometry in which a beam
just wide enough to cover only the area of interest is

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Cotti & Campisi

Fig. 12. Computerized tomography (CT) examination of a fibrous dysplasia of the mandible. (a) Panoramic image of
the mandible, demonstrating an extensive dysplastic area (long arrow); within this area a periapical lesion originating
from the lower left second molar is shown (short arrow). (b) Intraoral radiograph showing the same lesion in a restricted
view. (c) Axial CT section demonstrating the increased bucco-lingual width as well as the areas of radiopacity (short
arrow) and radiolucency (long arrow). (d) Three panoramic slices reconstructed along the planning line; they show the
different areas of radiolucency and sclerosis within the bone pattern (arrows).

used. This is done in order to reduce the radiation dose

to the patient.
In an experimental set-up with a single molar and a
dry mandible, it has been shown that local CT
reconstructions give a quality of image comparable to
that of a CT using wide beam geometry. The resolution
of the image was diagnostically adequate (33). Micro
CT uses stacked fan-beam geometry and produces 3D
reconstruction of the objects examined. Such a desktop
micro-CT has been used to reconstruct root canals
without requiring a previous disassembly of the teeth
(34). In recent evaluations on induced periapical
lesions in mice, micro-CT, performed with 150
microtomographic slices of 17 mm increments, gave
3-D morphometrical data on the study of periapical
lesions that compared well with the histology (35). The
authors found that the widest area of the destructive

64

pattern of induced periapical lesions appeared right

under the apical foramen, and that the resorptive
lesions were not uniform in nature. They also noticed
that the 2-D measurement of area of the periradicular
lesions and the 3-D measurement of their volume were
highly correlated. Currently, the use of micro-CT may
be limited to in vitro measurements of small samples
due to the high radiation dose required. Experimental
systems with reduced dose are being tested.

Magnetic resonance imaging (MRI)

Nuclear magnetic resonance, also called MRI, has been
available as an imaging technique since 1984.
MRI combines the use of a magnetic field and some
radio frequency antennas called coils. During the MRI

Advanced radiographic techniques for the detection of lesions in bone

tissues and vessels whereas it does not provide
great details of the bony structures. The strength of
the MRI system magnetic field is measured in metric
units called Tesla. In MRI bright means high signal
intensity, dark means low signal intensity, with all the
intermediate shades, i.e.: dense bone 5 dark, air 5 dark, fat 5 bright. Using a special program, STIR
(short tau inversion recovery, fat annulling sequences),
water and blood will appear bright. The pictures of
MRI will look, as in CT, like sections or cuts.
Disadvantages of MRI are a longer scanning time
compared to CT, and a strong magnetic field generated, which is why it cannot be used in patients carrying
a pacemaker or metal pieces in the areas to be
investigated. It is an expensive examination and in
most of the systems the patient must be placed in a
narrow tube (3639).

Application of MRI to endodontics

Fig. 13. Lesion in the mandible as shown in panoramic

radiograph and computerized tomography examination.
(a) Panoramic radiograph showing a round radiolucent
lesion in the central mandible (arrow). (b) Axial slices
through the mandible. The lesion has caused expansion
and erosion of the external cortical plate (arrows).

exam a magnetic field is created: this causes the protons

in the atoms of water, within the tissues to be examined,
to line up. Then pulses of radio waves are sent from a
scanner towards the tissue. A high-frequency pulse
moves many of the protons out of alignment. As the
nuclei realign back into proper position, they send out
the radio signals (resonance) that are captured by a
radio antenna. The signals are received and measured
from a computer system that analyses and converts
them into an image of the part of the body being
explored. Different atoms in the body absorb radio
waves at different frequencies under the influence of
the magnetic field. The way in which absorption takes
place is measured and used by the computer to
construct the images.
Magnetic resonance is a completely non-invasive
technique since it uses radio waves; it also allows
acquisition of direct views of the body in almost all
orientations. Its best performance is in showing soft

Application of MRI to the dental field started in the late

nineties. Studies have been reported on the temporomandibular joints (36), on the assessment of the
jawbones prior to implant surgery (37), and on the
differential diagnosis of ameloblastoma and odontogenic keratocysts (38).
Gahleitner and his group were the first to apply MRI
to the study of the jaws and teeth (39). They evaluated
38 patients, seven of whom were healthy, the others
presenting with different dentally related conditions
(pulpitis, transplanted teeth, dentigerous cysts) They
showed that MRI gives good imaging of the jaw bones,
including teeth, pulp spaces and periapical tissues.
Pulps were better visualized after administration of a
contrast medium. Edema in the periapical region was
detectable. Recently a very comprehensive review on
MRI and its relationship with the teeth and periapical
tissues has been published (40). An open MRI system
was used to examine the dental and periapical status in
normal patients and in patients who had been
diagnosed with periapical pathosis. Slices of 3 mm were
undertaken in the transverse, coronal, and oblique
sagittal planes using T1-weighted spin echo, STIR fat
annulling sequences, and fast low angle shot. In MRI
enamel and dentine appear black, the pulp chamber and
canal either white or light gray, root fillings are dark.
The cortical bone is a black area outlined by lighter, soft
external tissues and internal fatty marrow. On STIR (fat

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Cotti & Campisi

66

Advanced radiographic techniques for the detection of lesions in bone

annulled scans), fatty marrow has a low signal and
appears dark gray. Periapical lesions are clearly
seen in the images both on coronal and transverse
sections. Any interruption of the cortical plates is also
easily seen. Areas of bone sclerosis, which usually
surround the periapical lesion, are seen as very low
signals (black). On fast low angle shots T1, they are
seen as moderate signals (gray) as opposed to the fatty
medullary marrow, which gives a strong white signal.
This appearance is probably due to the replacement of
bone marrow by inflammatory exudates. The same
periapical lesions on STIR, on the contrary, are
visualized as low-gray to bright white areas: indicating
that the area has a high water content and may be
oedematous in nature. The altered areas visualized on
MRI are considerably more extensive than the same
areas when they are observed in orthopantograms or
intra-oral radiographs. If the signal is low on T1 and
high on STIR, it may be deduced that the lesion is cystic
in nature. If the signal is mixed on both, then the lesion
is more likely to be a chronic mixed infection
(granuloma-infected cyst).
From these studies, it may be concluded that MRI
can be used for investigation of pulp and periapical
conditions, the extent of the pathosis and the anatomic
implications in cases of surgical decision-making (Figs
13ac and 14ad).
When an infective lesion like a periapical abscess
is expanding fast in the jawbones and in corresponding soft tissues, degenerating into osteomyelitis,
MRI becomes an elective diagnostic technique
(24).

Fig. 14. Lesion of Fig. 13, as shown in magnetic

resonance imaging (MRI) examination. (a) Coronal slice
in MRI showing a well circumscribed solid lesion in the
central mandible. The lesion is visible (big arrow). The
pulp chamber of the teeth is visible in this image (small
arrow). (b) MRI, axial slice through the mandible; the
lesion extends through the external cortical plate and
through the soft tissues (small arrow). On the left side of
the image, the dark area is an artefact due to the metallic
restoration of the tooth (big arrow). (c) MRI, axial slices
in T1 fat sat sequences; the lesion and its relationship with
the soft tissues is very clearly showed (arrows). (d) MRI,
lateral slice showing the same lesion (arrow). On the MRI
sequences, the solid nature of the lesion, its involvement
of the soft tissues, its blood content, are easily detected.
The MRI diagnosis was of a granulomatous lesion.

Ultrasound real-time imaging

Real-time ultrasound imaging, also called real-time
echotomography or echography has been widely used
diagnostic technique in many fields of medicine. The
imaging system in echographic examination is based on
the reflection of ultrasound waves (US) called echos.
The US oscillating at the same frequency are generated,
as a result of the piezoelectric effect, by a synthetic
crystal and are directed towards the area of interest via
an ultrasonic probe. The different biological tissues of
the body possess different mechanical and acoustic
properties. When the US encounter the interface
between two tissues with different acoustic properties,
they undergo the phenomena of reflection and refraction. The echo is the part of the US that is reflected
back to the crystal. The intensity of the echos depends
on the difference in acoustic properties between two
adjacent tissue compartments: the greater the difference, the greater the amount of reflected ultrasound
energy, and the higher the echo intensity. Echos are
then transformed into electrical energy and into light
signals in a computer inside the machine. The movement of the ultrasonic probe produces the US images
seen on the monitor over the part of interest in the
body. Since each movement gives one image of the
tissue and there are an average of 30 images per second,
the exam will appear in the monitor as moving images.
The interpretation of the gray values of the images is
based on the comparison with those of normal
tissues. The color power Doppler is based on the red
blood cells Rayleighs scattering effect and on the
Doppler effect. When applied to the echographic
examination, it allows representing the presence
and direction of the blood flow (Doppler), under
the format of color spots superimposed to the images
of blood vessels (color), and the intensity of the
Doppler signal with its modifications in real time
(power) (40, 41).
The intravenous injections of substances (contrast
mediums) will increase the echogenicity of the blood
and will render the echo-power-Doppler exam more
sensible by creating a major difference of acoustic
impedance in the area of interest (41). Ultrasound
imaging is considered to be a safe technique, but the
energy of US waves is absorbed in the form of heat from
the biologic tissues that need to be controlled. This
potentially adverse effect of the system depends on the
time of application of the sound energy; therefore, one

67

Cotti & Campisi

seeks to limit the number and the repetitions of the
exams (4244). In any case the risk is much lower than
the risk associated with radiographic investigations
(4044).

Ultrasound imaging in endodontics

The application of echographic examination to the
study of endodontic disease has been attempted with
success (45). The technique is easy to perform and may
show the presence, exact size, shape, content and
vascular supply of endodontic lesions in the bone. The
echographic probe, covered with a latex protection and
topped with the echographic gel, should be moved in
the buccal area of the mandible or the maxilla,
corresponding to the root of the tooth of interest.
The regular probe, so far, has been performing well
even if a more specific instrument for dental use should
be made available. Alveolar bone appears as a total
reflecting surface (white) if healthy; the contours of the
roots of the teeth are even whiter (Fig. 15a) this tissue is
then considered hyperechoic. A fluid-filled cavity in the
bone appears as a hypo-reflecting surface (dark) to
different degrees, depending of the cleanliness of the
fluid (hypoechoic): a simple serous filled cavity has no
reflection (anechoic or transonic) (Fig. 15b). Solid
lesions in the bone have a mixed echogenic appearance, which means their echos are reflected with
various intensities (light grayish) (Fig. 15c). If the bone
is irregular or resorbed in proximity of the lesion, this
can be seen as an inhomogeneous echo; if the bony
contour limiting a lesion is reinforced, then it is very
bright. Major anatomic landmarks, such as the mandibular canal, mental canal, and maxillary sinus, are
clearly distinguished and mostly transonic. At the color
power Doppler, the vascularization within the lesion
and around it can be seen; the details of it are enhanced
by the use of contrast mediums. A differential diagnosis
"

Fig. 15. Ultrasound real-time imaging of the jaws. (a)

Echographic view of the profile of the mandible: the
contours of the roots are visible (arrows); the image
represents a hyperechoic area where total reflection
occurs. (b) Cystic lesion as seen in the ultrasound image
(circled): it is an anechoic or transonic cavity where no
reflection occurs: the reinforced bony contour of this
lesion is hyperechoic (arrow). (c) Periapical lesion as seen
in the ultrasound image (circled). It is an echogenic area
where echoes are reflected back at different intensities.

68

between cystic lesions and granulomas may be done

based on the following principles (46): cystic lesion: a
transonic, well-defined cavity filled with fluids and with
no evidence of internal vascularization at the color
power Doppler (Fig. 16a, b); granuloma: a distinct
lesion showing not well-defined contours, which can be

Advanced radiographic techniques for the detection of lesions in bone

Fig. 17. Ultrasound real-time imaging of a lesion of

endodontic origin in the mandible. (a) Periapical lesion
corresponding to the periradicular area of the lower left
first bicuspid, as seen in the radiograph. (b) The same
lesion as seen in the ultrasound image (framed): it is an
echogenic area showing the presence of vascular supply
at the color power doppler (blue and red spots); it was
diagnosed as a periapical granuloma and the diagnosis was
confirmed by the histopathologic report.

Fig. 16. Ultrasound real-time imaging of a periapical

lesion of the maxillary bone. (a) Periapical lesion as seen in
the intraoral periapical radiograph; the lesion involves the
periapical area of the upper left front teeth. In this image,
it is not possible to visualize the extension of the lesion in
the bone. (b) The same lesion as seen in the ultrasound
image (circled): it is a transonic cavity with reinforced
hyperechoic bony contour (arrow); it shows a fluid
content. The major diameter is indicated by the dotted
line. The echographic diagnosis was of cystic lesion; the
histopathologic report confirmed it.

frankly corpusculated (echogenic), or may show both

corpusculated and hypoechoic areas (Fig. 17a, b),
exhibiting a vascular supply at the color power
Doppler with or without contrast medium (Fig. 18).
The sensitivity of the technique makes possible
a distinction between serous and inflammatory exudates in cysts. However, at its current stage of
development, the echographic examination may not
help in distinguishing between other kind of cystic
conditions (i.e. keratocysts, traumatic bone cyst,
developmental cyst) as the cavity is well visualized and
its contents, be it fluid or particulate, can hardly be
distinguished (Fig. 18a, b). Fibrous tissue within a
lesion maybe distinguished with more details; also
calcified particles can be observed.

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Cotti & Campisi

Fig. 18. Picture representing the echo color power

Doppler applied to the echographic examination of the
previous case. In the upper portion of the picture, the
echographic image is visualized (ehco), together with the
colored spots representing the presence and direction of
the blood flow (color-Doppler). In the lower part the
intensity of the Doppler signal with its time modification
is pictured (power).

Conclusions
The possibility to monitor biological changes in the
diseased bone in the field of periapical disease is always
challenging. From time to time it may be important to
be able to see a lesion in its real extension, to evaluate its
content, to assess its precise relationship to anatomic
landmarks such as the mandibular canal, mental foramen, incisal foramen, floor of the maxillary sinus, etc.,
and to speculate on its expansion, vascularization,
pattern of bone destruction, and evolution in time.
When it comes to the most common needs for
differential diagnosis of lesions of the jaws, the issue is
even more urgent. Many relatively new special imaging
techniques are available today that may reach these
goals. Some are well established, others are currently
being tested with promising results. It is necessary to
stress that most of the alternative imaging techniques
may be very expensive, or less safe for the patient
because of high radiation doses. Others may be
extremely sensitive but difficult to interpret. They
should therefore be used with the proper indication,
and performed by well-trained professionals.
Dental CT is now universally considered a useful
complement to conventional radiology techniques. In
endodontics, it may be useful for identification of large
lesions and their relationship to anatomic structures

70

Fig. 19. Echographic examination of a traumatic bone

cyst of the mandible. (a) Panoramic radiograph showing
the wide radiolucent lesion in the anterior mandible. (b)
Ultrasound imaging of the same area: it appears as a cystic
lesion; the lesion diagnosed as a traumatic bone cyst with
sero-sanguinous content.

prior to endodontic surgery as well as for evaluation of

the pattern and the content of the lesions when there
may be a diagnostic challenge (different kind of cysts,
unilocular ameloblastoma, dysplastic forms and suspected tumours). Furthermore, CT must be prescribed
with the specific indication of the area of interest and
possibly the number of scans required. It should not be
repeated if not strictly necessary. Alternative CT
techniques are promising, but still under evaluation;
therefore, they cannot be adopted for routine use so far.
Local CT appears particularly promising. Micro-CT is
still confined to the field of research, especially in
correlation with clinical and histopathological investigations, which is important for the knowledge of the
characteristics and mechanisms of these pathologic
conditions. MRI, as stated before, is extremely
expensive; it should be left to differential diagnostic

Advanced radiographic techniques for the detection of lesions in bone

problems that mostly involve abnormal spreading of
lesions in the bones, evaluation of lesion content,
involvement of soft tissues, nerves and vascular supply.
Ultrasound imaging seems to be a better compromise
in that is not as expensive as CT and MRI or dangerous
in terms of radiation risk as CT. If conducted with a
limited number of examinations it does not entail
biologic adverse effects. Clinically it may be useful for
dimensional assessment of the pathologic areas and for
the specific evaluation of fluid versus solid content of
the lesions. There is a definite future in the study of the
blood flow and the way it relates to the pathogenesis
and expansion of the bony defects. Ultrasound has
potential in the differential diagnosis of cysts versus
granulomas; cystic content may be defined as clean or
particulate. The technique may certainly be used in
research on periapical pathology. Its major drawback,
besides the fact that echographic machines are not so
commonly found, is that image interpretation is quite
difficult and requires extensive operator training and
experience.

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